Medical errors and the adverse events they lead to are common and expensive. Some researchers and influential groups like the Institute of Medicine believe that team functioning should be improved as one method of decreasing errors and improving patient safety. However, fundamental questions exist about the relationships among teamwork and error in healthcare. Many of these questions have been answered for the aviation industry and the research group that led that effort is a critical element of the research team assembled for this proposal. We hypothesize that specific error management behaviors that comprise teamwork are correlated with errors in delivering care to pre-term infants during their initial resuscitation and during the first 90 minutes of care in the neonatal intensive care unit (NICU). To test this and other hypotheses we will: 1. Adapt the aviation model of teamwork and error to NICU teams by conducting focus groups with NICU personnel. 2. Analyze videotapes of a prospective cohort of pre-term infants recorded during two critical periods: initial resuscitation and the first 90 minutes of admission to the NICU. 3. We will also use the data derived from Aims 1 and 2, along with data from our previous work in this organization, to design an intervention to improve these behaviors and address elements of the organizational and professional culture that influence the frequency of error.